Headache

Hx: During a busy shift, you see a 30 yo female complaining of severe headache. She notes that she has a history of recurrent headaches and starting 3 months ago they have been associated with left sided numbness and weakness. She is not interested in engaging in a lengthy history because of her pain, but you push her to tell you more. She notes that she was seen at another hospital and was told she had a stroke. You press her for details regarding the admission but she says she only spent a few hours in the emergency department and then was sent home. She denies ever being admitted or seeing a neurologist. She does, however, note that she did have resolution of her symptoms, but they return on a regular basis, lasting days at a time, and resolve spontaneously as the headache improves. Today she has similar symptoms with left sided weakness involving the face, arm, and leg associated with a severe left sided headache.

Past Med. Hx– none

Social Hx– She is an intermittent smoker (less than a pack a week), no drugs, rare alcohol.

Exam:
• General- she is laying on her left side in the stretcher, in a dark room. She is minimally cooperative with the examination.
• Vital – pulse 80, BP 150/75, Temp 98, and O2 sat 99% on room air.
• Cardiovascular- RRR, no murmurs, normal pulses x 4 extremities.
• Lungs – CTA B
• Abdomen- soft, non-tender, non-distended.
• Neurological- left lower facial droop, left arm and leg weakness relative to the right but without drift. Sensation is normal bilaterally. Speech is clear. She is awake and alert and minimally compliant with the exam due to her headache and photophobia. She refuses to comply with finger to nose testing.

Diagnostics: A complete blood count and metabolic profile are normal. A CT scan of the brain shows a left thalamic hypodensity, otherwise no abnormalities. A report of a prior head CT, performed 2 months ago at an outside institution, makes no mention of any hypodensities.

Hospital Course: The patient is admitted and a neurology consultation is obtained. During an MRI/MRA she is noted to have a carotid dissection with evidence for multiple ischemic infarcts. Vascular surgery is consulted and the patient is begun on antiplatelet therapy and she clinically improves. During her hospital course, family members note that the patient had several hemi-plegic episodes over the past 3 months and would spend days in bed until her symptoms improved. She had only been evaluated once before and they note the patient was told this was likely a complex migraine.

Discussion: Carotid dissection is a common cause of stroke in young patients, under age 50. Up to 20% of strokes in this population may be due to arterial dissection with emoblizaiton. The median age for dissection patients in the North America is 44-46. Most are not associated with connective tissue abnormalities and the most common cervico-cephalic vessel involved is the extra-cranial portion of the internal carotid artery. First line therapy is aimed at anticoagulation to prevent vessel stenosis and embolization. In patient who fail anticoagulation, endovascular stenting has been reported to be successful. The hallmark is early recognition which can be challenging as there is often no history of preceding cervical trauma. This case highlights the challenges in making the diagnosis when the patient has been given a prior diagnosis and is unwilling or unable to fully comply with an adequate history and physical examination. Carotid artery dissection should remain high on the list of causes for stroke symptoms in this young population.